Allograft reconstruction for massive, irreparable rotator cuff tears

Bridging repair reinforced with artificial ligament as an internal brace for irreparable massive rotator cuff tears

BACKGROUND

The irreparable massive rotator cuff tear (IMRCT) is challenging to manage. Although various surgical options have been proposed to treat IMRCTs, the optimal surgical technique remains controversial. Arthroscopic bridging patch repair is clinically used for treating IMRCTs, but the healing rate of the patch graft is negatively affected by superior shift of the humeral head. This study aimed to evaluate the clinical efficacy of artificial ligament as an internal brace (IB) reinforcing fascia lata autograft bridging repair (ABR) in the treatment of IMRCTs.

METHODS

The data of 50 patients with IMRCTs who underwent ABR reinforced with artificial ligament as an IB (ABR + IB) (internal brace group) or ABR alone (control group) were retrospectively evaluated preoperatively and at 2-year follow-up. Clinical outcomes were assessed based on the shoulder activity, of which the strength was measured using a 0-10 points manual muscle test scale, American Shoulder and Elbow Surgeons score, and visual analog scale for pain. Imaging outcomes were evaluated based on acromiohumeral distance (AHD), Hamada grade, Goutallier grade, and the status of fascia lata grafts as per radiographs or magnetic resonance imaging findings.

RESULTS

Both groups showed significantly better results in shoulder activity, American Shoulder and Elbow Surgeons score, visual analog scale score, and AHD at 2-year follow-up compared with preoperative levels (P < .001). Compared with the control group (n = 24), the internal brace group (n = 26) had better mean AHD (7.0 ± 1.4 mm vs. 5.9 ± 1.0 mm, P = .002), mean improvement in AHD (3.3 ± 1.5 mm vs. 2.0 ± 0.6 mm, P < .001), healing rate of autografts (92.3% vs. 54.2%, P = .002), and improvement rate of Hamada grade (73.1% vs. 41.7%, P = .025) at 2-year follow-up. No significant differences were found in active elevation, active external rotation, active internal rotation, abduction strength, external rotation strength, internal rotation strength, American Shoulder and Elbow Surgeons score, or visual analog scale between the 2 groups at 2-year follow-up.

CONCLUSION

Both the ABR + IB and ABR improved the postoperative short-term clinical and imaging outcomes in managing IMRCTs, the ABR + IB is statistically superior to ABR alone in terms of healing rate of the bridging graft, AHD, and Hamada grade at 2-year follow-up, while further clinical investigations with larger sample size and longer follow-ups are required to validate the clinical significance of this novel technique for IMRCTs.

Middle trapezius tendon transfer using Achilles allograft for irreparable isolated supraspinatus tendon tears effectively restores the superior stability of the humeral head without restricting range of motion: a biomechanical study

BACKGROUND

Middle trapezius tendon (MTT) transfer has been suggested for promising treatment of irreparable isolated supraspinatus tendon tears (IISTTs). However, there have been no attempts to assess the biomechanical efficacy of MTT transfer. This study aims to evaluate the biomechanical efficacy of MTT transfer in the setting of IISTTs.

METHODS

Eight fresh frozen cadaveric shoulders were tested in 3 conditions: (1) intact rotator cuff, (2) IISTT, and (3) MTT transfer using Achilles allograft for IISTTs. Total humeral rotational range of motion (ROM), superior translation of the humeral head, and subacromial contact characteristics were measured at 0°, 20°, and 40° glenohumeral abduction (representing 0°, 30°, and 60° shoulder abduction). Superior translation and subacromial contact pressures were measured at 0°, 30°, 60°, and 90° external rotation (ER). Two different MTT muscle loading conditions were investigated. A linear mixed effects model and Tukey post hoc test were used for statistical analysis.

RESULTS

Total ROM was significantly increased after IISTT at 20° abduction (P = .037). There were no changes in total ROM following MTT transfer compared to the IISTT condition (P > .625 for all comparisons). The IISTT condition significantly increased superior translation compared to the intact rotator cuff condition in 0° and 20° abduction with all ER angles (P < .001), 40° abduction-30° ER (P = .016), and 40° abduction-60° ER (P = .002). MTT transfer significantly decreased superior translation of the humeral head at all abduction angles compared to the IISTT condition (P < .026). MTT transfer significantly decreased peak contact pressure by 638.7 kPa (normal loading) and 726.8 kPa (double loading) at 0° abduction-30° ER compared to the IISTT condition (P < .001). Mean contact pressure was decreased by 102.8 kPa (normal loading) and 118.0 kPa (double loading) at 0° abduction-30° ER (P < .001) and 101.0 kPa (normal loading) and 99.2 kPa (double loading) at 0° abduction-60° ER (P < .001). MTT transfer at 20° abduction-30° ER with 24 N loading significantly decreased contact pressure by 91.2 kPa (P = .035).

CONCLUSIONS

The MTT transfer biomechanically restored the superior humeral head translation and reduced the subacromial contact pressure in a cadaveric model of IISTT, while not restricting total ROM. These findings suggest that MTT transfer may have potential as a surgical treatment for IISTTs.

Reinforcement Techniques in Arthroscopic Repair of Large-to-Massive Rotator Cuff Tears: A Comparative Study of Superior Capsule Reconstruction and Patch Graft Augmentation

Background: Large-to-massive rotator cuff tears (LMRCTs) present challenges in achieving successful repair due to factors such as muscle atrophy and tendon retraction. Arthroscopic rotator cuff repair (ARCR) with reinforcement techniques like superior capsule reconstruction (SCR) or patch graft augmentation (PGA) has emerged as a less invasive option to improve shoulder joint stability and prevent retear. This study aimed to compare the clinical and radiological outcomes of SCR and PGA as reinforcement techniques for the arthroscopic repair of LMRCTs. Methods: A single-center retrospective study was conducted on patients undergoing LMRCT repair between January 2019 and December 2021. Patients were divided into two groups: those receiving SCR (Group 1) and those receiving PGA (Group 2). Various clinical parameters including range of motion, functional scores, and radiological assessments were evaluated preoperatively and six months postoperatively. Results: Both SCR and PGA techniques demonstrated significant improvements in the range of motion and clinical scores postoperatively. However, Group 2 showed higher postoperative SST and UCLA scores compared to Group 1. Radiologically, there was a slightly higher retear rate in Group 2, although this was not statistically significant. Group 2 also had a shorter mean duration of surgery compared to Group 1. Conclusions: In the arthroscopic repair of LMRCTs, both SCR and PGA techniques exhibit favorable clinical and radiological outcomes. Despite the simplicity of PGA compared to SCR, it offers comparable results with a shorter surgical duration, making it a feasible reinforcement option for surgeons.

A retrospective comparative study of surgical outcomes following femoral fascia patching and iliotibial ligament bony patching for primary irreparable rotator cuff tears in a geriatric population

INTRODUCTION

We performed two surgical techniques for primary irreparable rotator cuff tears: a patch technique using the femoral fascia as a graft (F technique) and a patch technique using the bony iliotibial ligament (I technique). We then evaluated the outcomes of both surgical methods.

MATERIALS AND METHODS

This study included 28 patients who were diagnosed with primary irreparable rotator cuff tears from April 2008 to April 2014. Among them, 13 underwent the F technique, whereas 15 underwent the I technique. Each clinical shoulder score was evaluated preoperatively and 2 years after surgery. The cuff integrity was evaluated via magnetic resonance imaging 2 years after surgery, with cases suffering a retear after surgery undergoing retear site examination. In group I, computed tomography (CT) was performed 3-4 months after surgery to investigate the bony part of the patch and bony fusion of the footprint.

RESULTS

Both groups showed significant improvements in the pre- and postoperative mean clinical score values. Group I had significantly better postoperative scores than group F. Postoperative retear rates were 33.3% and 76.9% for groups I and F, respectively, with group I having a significantly lower retear rate (P = 0.03). All 5 retears in group I were located at the suture between the residual rotator cuff and the graft, whereas 7 of the 10 retears in group F were located at the fixation of the graft and footprint and the remaining 3 were central. CT results in group I showed that all 15 patients had bony fusion between the bony part of the patch and the footprint.

CONCLUSION

The I technique was significantly superior to the F technique in terms of postoperative clinical scores and retear rates, suggesting its advantage for rotator cuff tissue reconstruction.

Superior Capsular Reconstruction Versus Middle Trapezius Tendon Transfer for Isolated Irreparable Supraspinatus Tendon Tears: Static Versus Dynamic Reconstruction

BACKGROUND

Both superior capsular reconstruction (SCR) and middle trapezius tendon (MTT) transfer can be performed in nonarthritic young and active patients with isolated irreparable supraspinatus tendon tears (IISTTs). However, to our knowledge, no comparative clinical studies have been conducted on these procedures.

PURPOSE

To evaluate and compare the clinical and radiological outcomes of SCR and arthroscopic-assisted MTT transfer in patients with IISTTs.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 60 patients with IISTTs were categorized into 2 groups according to the surgical procedure-Group S underwent SCR (n = 34); Group M underwent MTT transfer (n = 26). The clinical outcomes included the visual analog scale score for pain, active shoulder range of motion, American Shoulder and Elbow Surgeons score, and University of California, Los Angeles, shoulder score. Radiological outcomes included the assessment of the acromiohumeral distance, progression of cuff tear arthropathy (Hamada grade), subacromial bone erosion, and graft failure.

RESULTS

The mean follow-up time was 39.3 ± 5.2 months (range, 26-59 months) and 37.6 ± 9.8 months (range, 27-54 months) in Group S and Group M, respectively. Significant improvements in clinical outcomes were observed in both groups, while the active forward flexion (148.2°± 24.1° vs 165.9°± 8.7°; P = .003) and abduction (131°± 37.3° vs 152.5°± 17.9°; P = .035) were significantly higher in Group M at the final follow-up. No significant differences were found in the postoperative Constant, American Shoulder and Elbow Surgeons, and University of California, Los Angeles, shoulder scores between the 2 groups. Radiologically, although no difference was found in the Hamada grade at the final follow-up between the 2 groups (P = .143), the rates of acromial wear (58.8% vs 15.4%; P < .001) and graft retear (47.1% vs 7.7%; P < .001) were significantly higher in Group S than in Group M.

CONCLUSION

Both SCR and MTT transfer improved the overall clinical outcomes of IISTTs postoperatively, whereas MTT transfer was superior to SCR in terms of active forward flexion and abduction range of motion. Although higher rates of graft failure and subacromial bone erosion were observed in Group S, no difference was found in the clinical scores between the 2 groups at the short-term follow-up. However, further well-structured, prolonged comparative trials should be conducted in the future.

Primary Rotator Cuff Bridging Reconstruction Shows Better Clinical and Radiographic Results Than Revision Bridging Reconstruction

Purpose

To evaluate the outcome of revision rotator cuff bridging reconstruction (BR) as compared to primary BR in a large cohort of patients.

Methods

A retrospective chart review was conducted for patients who underwent BR using dermal allograft for large/massive rotator cuff tears between 2010 and 2018. Patients who completed Western Ontario Rotator Cuff Index (WORC) and Disability of the Arm, Shoulder, and Hand (DASH) scores both pre- and postoperatively were included. Pre- and postoperative magnetic resonance imaging scans were compared to assess for differences in fatty infiltration, muscle atrophy, and graft status.

Results

Eighty patients met the inclusion criteria, including 43 patients who underwent BR as a primary surgery and 37 patients who underwent revision BR. The mean follow-up duration was 5.7 ± 1.9 years in the primary group and 5.8 ± 2.0 years in the revision group. Both WORC and DASH scores significantly improved from pre- to postoperatively for both the primary and revision groups (P < .05). The primary group had significantly better postoperative WORC and DASH scores at 6 months, 1 year, and final follow-up (P < .05). Failure rate of the graft was higher in the revision group compared to primary group (14.3% vs 6.1%, respectively; P = .337), and the amount of fatty infiltration of supraspinatus and infraspinatus muscles significantly improved in patients who received primary BR compared to revision BR (P < .05).

Conclusions

BR using dermal allograft for large/massive irreparable rotator cuff tears showed improvement of functional outcomes, with primary cases resulting in better improvement in patient-reported outcomes compared to revision cases. Primary BR was also associated with better postoperative fatty infiltration of supraspinatus and infraspinatus muscles.

Level of Evidence

Level III, retrospective cohort study.

Repair of chronic and large rotator cuff tears using extra-synovial autografts: An experimental study in rabbits

Purpose

To investigate whether and how extra-synovial autografts can enhance the reconstruction of chronic and large rotator cuff tears in a rabbit subscapularis model.

Methods

Twenty rabbits were used to create a large subscapularis tear bilaterally. Six weeks later, the right shoulder of each rabbit was operated to repair the tear with an extra-synovial autograft, whereas the left shoulder did not undergo any surgery. At 6 and 12 weeks after the second procedure, the specimens underwent biomechanical and histological evaluation. Six more rabbits were used only as a normal reference.

Results

Biomechanical evaluation demonstrated that the ultimate load to failure of the Graft group (184.1 ± 35.7 N) was significantly higher (p = 0.04) than that of the Defect group (144.5 ± 32.2 N) at 12 weeks after repair, rising to 76% of the normal subscapularis tendon tensile strength. Histological analysis revealed an enhanced healing environment with neoangiogenesis and decreased inflammatory response at the repair site. Moreover, the tendon maturing score of the Graft group increased substantially from 6 (15.8 ± 0.9) to 12 (23.1 ± 0.6) weeks after repair (p = 0.01).

Conclusion

In vivo data support the efficacy of extra-synovial autograft interposition in repairing chronic and large rotator cuff tears in a rabbit subscapularis model. The autografts were capable of enhancing the biomechanical properties of the repaired tendons, as evidenced by increased tensile strength, and forming new connective tissue simulating a fibrocartilage zone, as revealed by histological evaluation.

Level of Evidence

N/A.

Clinical effectiveness of superior capsular reconstruction using Teflon felt graft in the elderly for pain relief: a comparison using tensor fascia lata graft

Background

The graft material generally used in superior capsular reconstruction (SCR) may be a human dermal allograft or an autologous tensor fascia lata (TFL) graft. According to a previous biomechanical study, a dermal graft (3 mm) was found to be insufficient and a thicker and stiffer graft was required. However, graft-site mobility should be considered when harvesting TFL, especially in the elderly. We have used Teflon felt as a graft material for SCR in the elderly for pain relief. This study aimed to compare the pain-relieving effects and clinical outcomes between Teflon felt and TFL graft.

Methods

This study included 39 patients (Teflon felt group: 19 patients, TFL group: 20 patients) who underwent SCR with a minimum of 2-year follow-up. Patients with painful irreparable rotator cuff tears but with shoulder elevation (abduction or flexion) of at least 130° were included in the study. Shoulder range of motion, acromiohumeral distance, and the numerical rating scale were evaluated preoperatively and 2 years postoperatively.

Results

There were no significant differences between the Teflon felt and TFL groups in terms of shoulder elevation (151 ± 33° vs. 164 ± 15°, P = .57), acromiohumeral distance (8.3 ± 2.2 mm vs. 7.5 ± 2.5 mm, P = .14), and numerical rating scale (1.0 ± 1.2 vs. 0.9 ± 0.8, P = .93).

Conclusion

SCR with Teflon graft provided pain relief equivalent to TFL graft. It may be an effective treatment option in elderly patients for irreparable rotator cuff tears with respect to pain relief.

Biomechanical Comparison of Synthetic Polytetrafluoroethylene (PTFE) vs Human Dermal Allograft (HDA), 2 vs 3 Glenoid Anchors, and Suture vs Minitape in Superior Capsule Reconstruction

Background: Superior capsule reconstruction (SCR) is an option for the treatment of massive, irreparable rotator cuff tears. However, which materials yield the strongest constructs remains undetermined. Purposes: We sought to investigate whether SCR with polytetrafluoroethylene (PTFE) or human dermal allograft (HDA), 2 or 3 glenoid anchors, and suture or minitape resulted in better failure load properties at the patch-glenoid interface. Methods: We conducted a biomechanical study in 30 glenoid-sided SCR repairs in Sawbones models divided into 5 groups. Each was pulled to failure to assess mode of failure, peak load (N), stiffness (N/mm), yield load (N), peak energy (N m), and ultimate energy (N m). The 5 groups were as follows: group 1-PTFE, 2 anchors, and suture; group 2-PTFE, 2 anchors, and minitape; group 3-HDA, 2 anchors, and suture; group 4-HDA, 2 anchors, and minitape; group 5-PTFE, 3 anchors, and minitape. Results: Repairs failed by button-holing of suture/minitape. Group 5 had greater peak load, stiffness, yield load, and peak energy (384 ± 62 N; 24 ± 3 N/mm; 343 ± 42 N; 4 ± 2 N m) than group 3 (226 ± 67 N; 16 ± 4 N/mm; 194 ± 74 N; 2 ± 1 N m) or group 4 (274 ± 62 N; 17 ± 4 N/mm; 244 ± 50 N; 2 ± 1 N m) and greater ultimate energy (8 ± 3 N m) than all other groups. Conclusions: This biomechanical study of SCR repairs in Sawbones models found that yield load was greater in PTFE than HDA, 3 anchors were better than 2, and minitape was no better than suture.

Management of Massive Rotator Cuff Tears Without Arthropathy

Arthroplasty is not an optimal treatment for massive rotator cuff tears in patients who are active and without glenohumeral arthritis. Several surgical techniques have been developed for these patients, including arthroscopic rotator cuff repair with single-/double-row repair (with or without interval slides, margin convergence, graft augmentation), graft bridging, superior capsular reconstruction, tuberoplasty, and tendon transfers. Complete, tension-free, anatomic repair is ideal; however, tendon atrophy and retraction associated with massive tears often complicate repairs. All surgical treatments significantly increase patient-reported functional outcomes 1 year after intervention, with many treatments demonstrating improved mid-term and long-term outcomes. [Orthopedics. 2023;46(1):e1-e12.].

A collagen/PLA hybrid scaffold supports tendon-derived cell growth for tendon repair and regeneration

A rotator cuff tendon tear is a common shoulder injury with a relatively high rate of recurrence after surgical repair. In order to reinforce the repair and reduce the risk of clinical complications, a patch scaffold is typically sutured over the tendon tear to provide post-surgical mechanical support. However, despite considerable research effort in this area, a patch scaffold that provides both superior initial mechanical properties and supports cell proliferation at the same time has not yet been achieved. In this study, we engineered a collagen/poly(lactic acid) (COL/PLA) hybrid yarn to leverage mechanical strength of PLA yarn and the bioactivity of collagen. The COL/PLA yarns were used to fabricate a tissue engineering scaffold using textile weaving technology. This hybrid scaffold had a tensile strength of 354.0 ± 36.0 N under dry conditions and 267.2 ± 15.9 N under wet conditions, which was satisfactory to maintain normal tendon function. By introducing COL yarns into the hybrid scaffold, the proliferation of tendon-derived cells was significantly improved on the scaffold. Cell coverage after 28-days of in vitro cell culture was noticeably higher on the COL yarns compared to the PLA yarns as a result of a larger number of cells and more spread cell morphology on collagen. Cells spread in multiple directions on COL yarns, which resembled a more natural cell attachment on extracellular matrix. On the contrary, the cells attached to the PLA filaments presented an elongated morphology along the fiber's axial direction. Combining the mechanical robustness of PLA and the biological activity of collagen, the woven COL/PLA hybrid scaffold has shown its potential to be a promising candidate for tendon repair applications.

Latissimus dorsi transfer vs. lower trapezius transfer for posterosuperior irreparable rotator cuff tears

BACKGROUND

Latissimus dorsi transfer (LDT) and lower trapezius transfer (LTT) are effective treatment options for posterosuperior irreparable rotator cuff tears (IRCTs) in relatively young patients and elderly high-demand patients without arthritic changes. However, the optimal treatment option for patients with posterosuperior IRCT remains a subject of ongoing debate. This study aimed to compare clinical and radiologic short-term outcomes between arthroscopic-assisted LDT (aLDT) and arthroscopic-assisted LTT (aLTT) in patients with posterosuperior IRCT.

METHODS

This retrospective crossover study included patients who underwent aLDT or aLTT for posterosuperior IRCT and who had a minimum clinical follow-up time of 2 years after undergoing surgical procedures between January 2012 and June 2019. A total of 90 patients with posterosuperior IRCT were divided into 2 groups according to the surgical procedure: group D underwent aLDT (n = 48) and group T underwent aLTT (n = 42). Clinical outcomes comprised the visual analog scale score for pain, active shoulder range of motion (ROM), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, and activities of daily living that require active external rotation (ADLER) score. Radiologic outcomes included acromiohumeral distance (AHD). The progression of arthritis was evaluated using Hamada grade. Graft integrity was assessed using postoperative magnetic resonance imaging.

RESULTS

Significant improvements in clinical outcomes were observed in both groups. Active shoulder external rotation (P < .001), postoperative ASES score (P < .001), and ADLER score (P < .001) were significantly higher in group T than in group D. AHD at 2-year follow-up was significantly higher in group T than in group D (P < .001). The rate of progression of arthritis was significantly higher in group D (31.3%) than in group T (7.1%) (P = .031).

CONCLUSIONS

Although both LDT and LTT improved the overall clinical outcomes of patients with posterosuperior IRCT, LTT was superior to LDT in terms of shoulder ROM, functional improvement, and progression of arthritis. Our findings indicate that LTT may be the preferred treatment option for posterosuperior IRCT in relatively active and young patients.

Outcomes of arthroscopic-assisted middle trapezius tendon transfer for isolated irreparable supraspinatus tendon tears: minimum 2-year follow-up

INTRODUCTION

Middle trapezius tendon (MTT) transfer has been proposed as a feasible option for managing isolated irreparable supraspinatus tears (IISTTs). However, no clinical study has been attempted. This study aimed to evaluate clinical and radiologic outcomes of arthroscopic-assisted MTT transfer in patients with IISTTs.

METHODS

This retrospective study included patients who underwent arthroscopic-assisted MTT transfer using fascia lata autograft for IISTTs. Clinical outcomes, including pain visual analog scale (VAS), Constant, American Shoulder and Elbow Society (ASES), University of California Los Angeles (UCLA) shoulder scores and active range of motion (aROM), were assessed. Radiographic analyses included the acromiohumeral distance (AHD), Hamada grade, and transferred tendon integrity at the final follow-up.

RESULTS

Twenty-two patients (mean age: 63.3 ± 6.8 [51‒74] years; mean follow-up period: 28.9 ± 4.9 [24‒44] months) met the study criteria. The mean VAS, Constant, ASES, and UCLA scores improved postoperatively at the final follow-up (p < 0.001). The mean aROMs for forward flexion and abduction were significantly increased postoperatively. No significant changes of AHD (p = 0.105) and Hamada grade (p = 0.815) were observed postoperatively. One patient had a re-tear of the transferred tendon at the footprint site at the final follow-up.

CONCLUSION

In this minimum 2-year follow-up study of the novel aMTT transfer using fascia lata autograft, we found significant improvement in pain relief, clinical scores, and active forward flexion and abduction. Additionally, no significant progression of cuff tear arthropathy was observed at the final follow-up. Therefore, aMTT transfer could be a promising treatment option for patients with IISTTs. However, further multicenter and long-term trials are needed to verify its effectiveness.

LEVEL OF EVIDENCE

Retrospective case series, level IV.

Biomechanical Assessment of a V-Shaped Semitendinosus Allograft Anterior Cable Reconstruction for Irreparable Rotator Cuff Tears

PURPOSE

The purpose of this study was to biomechanically assess superior stability, subacromial contact pressures, and glenohumeral kinematics of a V-shaped anterior cable reconstruction with semitendinosus allograft (VST) in a massive rotator cuff tear (MCT) model.

METHODS

Eight cadaveric shoulders (mean age, 66 years; range, 48 to 72 years) were tested with a custom testing system used to evaluate superior translation, subacromial contact pressure, and glenohumeral kinematics at 0°, 20°, and 40° glenohumeral abduction and 0°, 30°, 60°, and 90° of external rotation (ER). Conditions tested included (1) native state, (2) MCT (complete supraspinatus and ½ infraspinatus), a (3) VST. The VST was secured medially on the glenoid with 1 anchor and on the greater tuberosity with a double-row configuration using 4 anchors.

RESULTS

The VST significantly decreased superior translation compared to the MCT at 0° and 20° glenohumeral abduction for 0°, 30°, and 60° humeral rotation and at 40° abduction and 0° degrees humeral rotation (P < .05). Superior translation following the VST remained significantly greater than the intact state at 0° abduction and 60° and 90° ER (P = .039 and 0.007, respectively) and 20° abduction and 30°, 60°, and 90° ER (P = .048, .003, and .004, respectively). The VST restored peak subacromial contact pressure to intact levels for all positions except 40° abduction and 60° ER. The VST did not statistically affect humeral head kinematics compared to the intact condition.

CONCLUSIONS

In a biomechanical model, a VST anterior cable reconstruction partially restores superior stability and reduces peak subacromial contact pressure associated with an MCT, without affecting glenohumeral kinematics. The technique may be a consideration in the treatment of an irreparable MCT with isolated anterior cable disruption.

CLINICAL RELEVANCE

The VST may provide an option for treatment of irreparable MCTs with anterior rotator cable disruption.

Interposition Graft Bridging Reconstruction of Irreparable Rotator Cuff Tears Using Acellular Dermal Matrix: Medium-Term Results

PURPOSE

In this study, we aimed to evaluate the medium-term clinical outcomes for patients who underwent bridging reconstruction.

METHODS

A retrospective chart review was conducted for all patients who underwent bridging reconstruction between 2010 and 2018. Patients who were missing either pre- or postoperative outcome scores were excluded. All included patients completed self-reported questionnaires (Western Ontario Rotator Cuff [WORC] and Disabilities of the Arm, Shoulder and Hand [DASH]) pre- and postoperatively at 6 months, 1 year, and annually thereafter. All scores were reported out of 100.

RESULTS

Ninety-one patients initially met our inclusion criteria, and 33 were excluded owing to lack of either pre- or postoperative outcome scores. Nine patients were lost to follow-up; therefore, 49 patients were finally evaluated, including 30 males (61.2%) and 19 females (38.8%) with an age of 59.6 ± 10.4 years (mean ± standard deviation) and mean follow-up of 5.3 years (range 2 to 9). Both WORC and DASH scores significantly improved from pre- to postoperatively (WORC: 69.6 ± 12.2 to 27.9 ± 23.7, P < .001; DASH: 51.5 ± 17.5 to 24.5 ± 23.0, P = .001). For WORC and DASH, 92% and 74% of patients, respectively, met the minimal clinical importance difference.

CONCLUSION

Our results showed that patients' clinical outcome scores significantly improved with an average of 5-year follow-up, which demonstrates that bridging reconstruction is a safe procedure with promising midterm clinical outcomes.

LEVEL OF EVIDENCE

IV, retrospective case series.

Achilles Tendon–Bone Block Allograft for Massive Rotator Cuff Tears With Bony Deficiency of the Greater Tuberosity: A Minimum 2-Year Follow-up Study

Background:

Massive rotator cuff tears associated with greater tuberosity bone loss are challenging to treat. Repairing the rotator cuff without addressing the greater tuberosity deficiency may result in poorer clinical outcomes.

Hypothesis:

Utilizing an Achilles tendon–bone block allograft to address both the massive rotator cuff tear and greater tuberosity bone loss concurrently can result in improved clinical outcomes.

Study Design:

Case series; Level of evidence, 4.

Methods:

The authors performed a retrospective study of patients treated between January 2011 and December 2018 with Achilles tendon–bone block allograft for massive rotator cuff tears associated with greater tuberosity bone loss. The inclusion criteria were massive rotator cuff tear and bony deficiency of the greater tuberosity; patients with a history of bony metabolism disease, connective tissue disease, and previous surgery to the wrist or elbow of the affected limb were excluded. Range of motion, visual analog scale for pain, Constant score, and Single Numeric Assessment Evaluation score were assessed preoperatively and at a minimum of 2 years postoperatively. Radiographs and ultrasound images were evaluated to assess allograft union and rotator cuff integrity.

Results:

Five patients (3 male and 2 female; mean age, 54.0 ± 12.2 years) were included in the study. The mean follow-up was 80.6 ± 33.7 months. Preoperative to postoperative values improved significantly on the visual analog scale (from 45.8 ± 25.5 to 14.5 ± 14.1; P = .04), Constant score (from 36.8 ± 7.9 to 73.5 ± 3.1; P < .001), and Single Numeric Assessment Evaluation score (from 42.5 ± 26.3 to 82.5 ± 10.4; P = .04). Forward flexion improved significantly from 53° ± 47° to 149° ± 17° (P = .03). Four of the 5 patients achieved bony union. One patient required removal of symptomatic hardware at 6 months postoperatively, and 1 patient required revision surgery at 1 year postoperatively because of progressive osteonecrosis of the humeral head.

Conclusion:

In patients with massive rotator cuff tears and a greater tuberosity bony deficiency, utilizing an Achilles tendon–bone block allograft to restore the bony defect and reinforce the rotator cuff repair was safe and effective. At a minimum of 2 years postoperatively, most patients demonstrated improved clinical outcomes, tendon healing, and graft incorporation.

Combining fascia lata autograft bridging repair with artificial ligament internal brace reinforcement : a novel healing-improvement technique for irreparable massive rotator cuff tears

AIMS

The aim of this study is to provide a detailed description of cases combining bridging patch repair with artificial ligament "internal brace" reinforcement to treat irreparable massive rotator cuff tears, and report the preliminary results.

METHODS

This is a retrospective review of patients with irreparable massive rotator cuff tears undergoing fascia lata autograft bridging repair with artificial ligament "internal brace" reinforcement technique between January 2017 and May 2018. Inclusion criteria were: patients treated arthroscopically for an incompletely reparable massive rotator cuff tear (dimension > 5 cm or two tendons fully torn), stage 0 to 4 supraspinatus fatty degeneration on MRI according to the Goutallier grading system, and an intact or reparable infraspinatus and/or subscapularis tendon of radiological classification Hamada 0 to 4. The surgical technique comprised two components: first, superior capsular reconstruction using an artificial ligament as an "internal brace" protective device for a fascia lata patch. The second was fascia lata autograft bridging repair for the torn supraspinatus. In all, 26 patients with a mean age 63.4 years (SD 6.2) were included.

RESULTS

All patients underwent more than two years of follow-up (mean 33.5 months (24 to 45)). All clinical scores were also improved at two-year follow-up (mean visual analogue scale 0.7 (SD 0.5) vs 6.1 (SD 1.2); p < 0.001; mean American Shoulder and Elbow Surgeons score 93.5 (SD 5.3) vs 42.5 (SD 10.8); p < 0.001; mean University of California, Los Angeles score, 31.7 (SD 3.7) vs 12.0 (SD 3.1); p < 0.001; and mean Constant-Murley score 88.7 (SD 3.5) vs 43.3 (SD 10.9); p < 0.001), and 24 of 26 fascia lata grafts were fully healed on MRI (92%). One patient had haematoma formation at the harvesting side of the fascia lata at two days postoperatively.

CONCLUSION

The fascia lata autograft bridging repair combined with artificial ligament internal brace reinforcement technique achieved good functional outcomes, with a high rate of graft healing at two-year follow-up. Although the short-term results are promising, further studies with a greater number of patients would provide clearer results. Cite this article: Bone Joint J 2021;103-B(10):1619-1626.

Bridging Allograft Reconstruction Is Superior to Maximal Repair for the Treatment of Chronic, Massive Rotator Cuff Tears: Results of a Prospective, Randomized Controlled Trial

BACKGROUND

Despite advances in surgical techniques, the use of maximal repair to treat large or massive rotator cuff tears results in a high retear rate postoperatively. Currently, no randomized controlled trials have compared the outcomes of maximal repair with interposition dermal allograft bridging reconstruction.

HYPOTHESIS

We hypothesized that large or massive rotator cuff tendon tears reconstructed using bridging dermal allograft would have better clinical outcomes 2 years postoperatively, as measured using the Western Ontario Rotator Cuff (WORC) index, than would those receiving the current gold standard treatment of debridement and maximal repair alone. We also expected that patients treated via bridging reconstruction using dermal allograft would have fewer postoperative failures as assessed using postoperative magnetic resonance imaging scans.

STUDY DESIGN

Randomized controlled trial; Level of evidence 1.

METHODS

A sample size of 30 patients (determined using a priori sample size calculation) with massive, retracted rotator cuff tears were randomly allocated to 1 of 2 groups: maximal repair or bridging reconstruction using dermal allograft. All patients completed questionnaires (WORC and Disabilities of the Arm, Shoulder and Hand [DASH]) preoperatively and postoperatively at 3 months, 6 months, 1 year, and 2 years. The primary outcome of this study was the WORC index at 2 years. Secondary outcomes included healing rate, progression of rotator cuff arthropathy, and postoperative acromiohumeral distance in both groups.

RESULTS

Patients treated via bridging reconstruction using dermal allograft had better postoperative WORC and DASH scores (23.93 ± 24.55 and 15.77 ± 19.27, respectively) compared with patients who received maximal repair alone (53.36 ± 31.93 and 34.32 ± 23.31, respectively). We also noted increased progression to rotator cuff arthropathy in the maximal repair group with an increased retear rate when compared with the reconstruction group (87% and 21%, respectively; P < .001). The acromiohumeral distance was maintained in the reconstruction group but significantly decreased in the maximal repair group.

CONCLUSION

Rotator cuff bridging reconstruction using a dermal allograft demonstrated improved patient-reported outcomes as measured using the WORC index 2 years postoperatively. This technique also showed favorable structural healing rates and decreased progression to arthropathy compared with maximal repair.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT01987973).

Improved Clinical and Radiologic Outcomes Seen after Superior Capsule Reconstruction using Long Head Biceps Tendon Autograft

PURPOSE

The objective of this study was to investigate the clinical and radiologic outcomes after superior capsule reconstruction (SCR) with biceps tendon (BT) for irreparable rotator cuff tears.

METHODS

The retrospective study period was May 2015 through February 2018. The average follow-up was 32 months (24-48 months) after surgery. Study inclusion criteria included an arthroscopic SCR performed using only our technique and minimum 2-year clinical follow-up by office visit and survey. Exclusion criteria included irreparable subscapularis tear and those patients lost to follow-up. This method enabled SCR by using the extraarticular portion and the intraarticular portion and making it 2 to 3 bundles by moving back and forth in the intraarticular area. Physical examination and functional scoring procedures were performed before surgery and at 3, 6, 12, and 24 months after surgery. Radiography and magnetic resonance imaging (MRI) were performed before surgery, after surgery (only radiography), and at 6 and 24 months after surgery.

RESULTS

Fifty-three shoulders involving 45 consecutive patients underwent BT technique for irreparable massive rotator cuff tears. The visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES), and constant score (CS) showed statistically significant improvement (VAS, 4.1-1.0; ASES, 60.9-82.7; and CS, 64.9-80.0; P < .0001). The shoulder active range of motion improved significantly by 23 for forward elevation (125.3-148.4; P < .0001) and by 12 for external rotation (38.0-50.9, P < .0001). The acromiohumeral distance (AHD) was significantly increased by 2.7 mm (4.4 ± 1.4 mm -> 7.1 ± 1.3 mm). No graft tear was detected in 39 patients (86.7%) during follow-up (24-48 months).

CONCLUSIONS

SCR via our technique improved clinical and radiologic outcomes. Thirty-five (77.7%) patients achieved 17-point improvement (the minimally clinically important difference) in the last follow-up of ASES score. Clinical scores and AHD had significantly increased, and good healed rate (86.7%) was observed in MRI.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Evaluating the role of graft integrity on outcomes: clinical and imaging results following superior capsular reconstruction

BACKGROUND

Superior capsular reconstruction (SCR) addresses massive, irreparable rotator cuff tears in young patients. The purpose of this study was to retrospectively evaluate clinical outcomes and graft integrity in patients following SCR.

METHODS

Thirty-four consecutive patients undergoing SCR by 2 surgeons with minimum 2-year follow-up were identified. Functional outcomes were obtained, including Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), visual analog scale (VAS), and Single Assessment Numeric Evaluation (SANE) scores. Graft integrity was evaluated on magnetic resonance images (MRIs).

RESULTS

Thirty-five shoulders in 34 patients were identified. Four patients underwent subsequent surgery. The mean preoperative scores were SST 21.6 ± 17.6, ASES 28.3 ± 10.1, SANE 50.6 ± 22.1, and VAS 6.6 ± 1.7. The mean postoperative outcomes were SST 79.1 ± 19.6, ASES 79.9 ± 17.4, SANE 74.3 ± 18.7, and VAS 1.5 ± 2.2. There was statistically significant improvement in SST, ASES, and VAS following SCR. MRI revealed graft failure in 62% (n = 13 of 21) of shoulders. Radiographic evidence of graft healing did not have any effect on SST, ASES, SANE, or VAS scores.

CONCLUSION

Given the high rate of graft failure without a significant difference in clinical outcomes, graft healing after SCR might not be an independent predictor of success. The improved clinical improvement in patients undergoing SCR may be due to other known beneficial aspects of the procedure, including partial rotator cuff repair, débridement, and biceps management.

Chronic Pectoralis Major Rupture Reconstruction With Interpositional Acellular Dermal Allograft

Background: Pectoralis major tendon (PMT) rupture commonly occurs in males 20 to 39 years of age. PMT rupture is most often associated with gym-based exercise, with attempted bench press being the most common causative event, but it is also associated with contact or impact sports. Delayed presentation, misdiagnoses, and chronic PMT rupture can result in a therapeutic dilemma.

Case Series: We present 2 cases of chronic PMT rupture that were operatively managed using acellular dermal allograft as an interposition graft. Patients’ final follow-ups were at 20 and 30 months, respectively. Strength in their pectoralis major muscle was well preserved on the contralateral side: 88% for patient 1 and 110% for patient 2.

Conclusion: Our reported technique using an interpositional acellular dermal allograft is a good option to treat chronic PMT rupture.

Superior Capsular Reconstruction of the Shoulder Using the Long Head of the Biceps Tendon: A Systematic Review of Surgical Techniques and Clinical Outcomes

Background and Objectives: Superior capsular reconstruction (SCR) with the use of a fascia lata autograft or a dermal allograft is an established treatment in treating irreparable rotator cuff (RC) tears. The long head of the biceps tendon (LHBT) has been recently proposed as an alternative graft for SCR. The purpose of this study was to present the surgical techniques and clinical studies utilizing the LHBT for SCR. Material and Methods: Medline, Scopus, and the Cochrane library were searched for relevant studies up to December 2020. The primary outcomes were pain intensity improvement and the incidence of RC and LHBT graft retears. Secondary outcomes were functional scores and acromiohumeral distance (AHD) improvements. Results: Nine studies described surgical techniques of SCR using the LHBT, and four clinical studies reported the outcomes of the technique. The mean pain intensity improved from 4.9 ± 2.3 to 1.6 ± 1.5 in terms of the visual analog scale, exceeding the minimum clinically important difference for adequate pain relief. Significant improvements were also noted in functional scores and AHD. When compared with other repair techniques for massive RC tears, i.e., the double-row repair, the transosseous-equivalent technique with absorbable patch reinforcement, and the traditional SCR with a fascia lata autograft, there were no significant differences in pain and function improvements. Conclusion: SCR using the LHBT is a useful treatment option for massive RC tears; it is equally effective with the traditional SCR and other established techniques. It presents numerous advantages being a safe, easy, time-saving, and cost-effective method. The only precondition for the technique is the presence of an intact LHBT. Additional clinical trials are necessary to determine which treatment is superior for treating massive RC tears, as well as to evaluate the long-term results of the technique.

Arthroscopic superior capsule reconstruction with Teflon felt synthetic graft for irreparable massive rotator cuff tears: clinical and radiographic results at minimum 2-year follow-up

BACKGROUND

Superior capsule reconstruction (SCR) was developed to improve shoulder function and relieve pain in patients with irreparable rotator cuff tears. Here, we investigated the clinical and radiographic outcomes and postoperative complications of SCR using a Teflon graft for reconstruction.

METHODS

Thirty-five consecutive patients with irreparable rotator cuff tears underwent SCR with Teflon grafts. The American Shoulder and Elbow Surgeons score, active shoulder elevation, shoulder muscle strength, visual analog scale pain scores, acromiohumeral distance, and postoperative complications were investigated. Data obtained before and after surgery were compared by using a paired t-test, χ² test, and 1-way analysis of variance, and data from 1-layer-graft SCR (15 patients; mean age, 75.1 years) and 3-layer-graft SCR (20 patients; mean age, 76.6 years) were compared by using an unpaired t-test. The average time to final follow-up was 42 months (range, 24-69 months).

RESULTS

SCR using Teflon grafts of either 1 or 3 layers significantly improved the American Shoulder and Elbow Surgeons score (by 20.8, P = .001 for a 1-layer graft; and by 31.1, P < .0001 for a 3-layer graft), visual analog scale score for motion pain (by 3.2, P = .001; and by 3.0, P < .0001), and muscle strength in shoulder abduction (by 11.9 N, P = .02; and by 10.9 N, P = .008). Active elevation at final follow-up was significantly greater in the 3-layer-graft group (142° ± 27°) than in the 1-layer-graft group (107° ± 42°) (P = .006). One year after SCR, acromiohumeral distance in the 3-layer-graft group was significantly greater than preoperatively (P = .04), whereas in the 1-layer-graft group, it was not. On postoperative magnetic resonance imaging, none of the patients in the 3-layer-graft group had graft tears, whereas 2 patients had graft tears and 1 patient had severe synovitis after 1-layer-graft SCR.

CONCLUSION

SCR using a Teflon graft-especially a 3-layer graft-significantly improved shoulder function and shoulder abduction strength, with pain relief and a low rate of postoperative complications. SCR using a Teflon graft can be a viable option for irreparable rotator cuff tears, especially when an autograft or allograft is not available.

Patch augmentation surgery for rotator cuff repair: the PARCS mixed-methods feasibility study

BACKGROUND

A rotator cuff tear is a common, disabling shoulder problem. Symptoms may include pain, weakness, lack of shoulder mobility and sleep disturbance. Many patients require surgery to repair the tear; however, there is a high failure rate. There is a need to improve the outcome of rotator cuff surgery, and the use of patch augmentation (on-lay or bridging) to provide support to the healing process and improve patient outcomes holds promise. Patches have been made using different materials (e.g. human/animal skin or tissue and synthetic materials) and processes (e.g. woven or mesh).

OBJECTIVES

The aim of the Patch Augmented Rotator Cuff Surgery (PARCS) feasibility study was to determine the design of a definitive randomised controlled trial assessing the clinical effectiveness and cost-effectiveness of a patch to augment surgical repair of the rotator cuff that is both acceptable to stakeholders and feasible.

DESIGN

A mixed-methods feasibility study of a randomised controlled trial.

DATA SOURCES

MEDLINE, EMBASE and the Cochrane Library databases were searched between April 2006 and August 2018.

METHODS

The project involved six stages: a systematic review of clinical evidence, a survey of the British Elbow and Shoulder Society's surgical membership, a survey of surgeon triallists, focus groups and interviews with stakeholders, a two-round Delphi study administered via online questionnaires and a 2-day consensus meeting. The various stakeholders (including patients, surgeons and industry representatives) were involved in stages 2-6.

RESULTS

The systematic review comprised 52 studies; only 15 were comparative and, of these, 11 were observational (search conducted in August 2018). These studies were typically small (median number of participants 26, range 5-152 participants). There was some evidence to support the use of patches, although most comparative studies were at a serious risk of bias. Little to no published clinical evidence was available for a number of patches in clinical use. The membership survey of British Elbow and Shoulder surgeons [105 (21%) responses received] identified a variety of patches in use. Twenty-four surgeons (77%) completed the triallist survey relating to trial design. Four focus groups were conducted, involving 24 stakeholders. Differing views were held on a number of aspects of trial design, including the appropriate patient population (e.g. patient age) to participate. Agreement on the key research questions and the outline of two potential randomised controlled trials were achieved through the Delphi study [29 (67%)] and the consensus meeting that 22 participants attended.

LIMITATIONS

The main limitation was that the findings were influenced by the participants, who are not necessarily representative of the views of the relevant stakeholder groups.

CONCLUSION

The need for further clinical studies was clear, particularly given the range and number of different patches available.

FUTURE WORK

Randomised comparisons of on-lay patch use for completed rotator cuff repairs and bridging patch use for partial rotator cuff repairs were identified as areas for further research. The value of an observational study to assess safety concerns of patch use was also highlighted. These elements are included in the trial designs proposed in this study.

STUDY REGISTRATION

The systematic review is registered as PROSPERO CRD42017057908.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 13. See the NIHR Journals Library website for further project information.

Subacromial balloon spacer implantation for patients with massive irreparable rotator cuff tears achieves satisfactory clinical outcomes in the short and middle of follow-up period: a meta-analysis

PURPOSE

This meta-analysis was performed systematically to evaluate the efficacy of subacromial balloon spacers for patients with massive, irreparable rotator cuff tears.

METHODS

Electronic databases, including Medline/PubMed, Embase and Cochrane Library, were systematically searched to identify studies evaluating the efficacy of subacromial spacers for patients with irreparable or massive rotator cuff tears. Meta-analyses were performed to pool the outcome estimates of interest, such as the total constant score (TCS) and its sub-score (pain, activities of daily living [ADL], range of motion [ROM], and strength), Oxford shoulder score (OSS), American Shoulder and Elbow Society scores (ASES) and numeric rating scale (NRS), as well as different outcomes at different time points in the follow-up period.

RESULTS

Ten studies with a total of 261 patients involving 270 shoulders were deemed viable for inclusion in the meta-analysis. The combined results demonstrated significant improvements in the TCS at the final follow-up (pooled mean difference = 26.4, 95% confidence intervals [CIs] 23.3 to 29.5). A sensitivity analysis and subgroup analysis, which were implemented based on two factors, different follow-up points and sub-scores (pain, ADL, ROM, and strength), revealed a consistent trend. The combined shoulder motion results demonstrated significant improvements in the forward flexion and external rotation (0° abduction) variables rather than in the abduction and external rotation (90° abduction) variables. Additionally, significant improvements in the OSS and ASES and a decrease in the NRS were observed in the middle of the follow-up period.

CONCLUSION

This meta-analysis indicated that subacromial balloon spacer implantation for patients with massive irreparable rotator cuff tears may achieve satisfactory outcomes between 3 months and 3 years of follow-ups. Although the short- and middle- term effect is significant, the long-term effect needs to be confirmed by large-sample randomized controlled trial.

LEVEL OF EVIDENCE

IV.

Use of implantable meshes for augmented rotator cuff repair: a systematic review and meta-analysis

OBJECTIVE

To appraise studies reporting on clinical effectiveness and safety of surgical meshes used to augment rotator cuff repairs (RCRs).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, Embase and Cochrane databases were searched between April 2006 and April 2020.

ELIGIBILITY CRITERIA

All studies evaluating adults (≥18 years) undergoing RCR were considered. There were no language restrictions.

DATA EXTRACTION AND SYNTHESIS

Screening, data extraction and quality appraisal were conducted by two independent reviewers. Meta-analysis was conducted using a random-effects models if ≥2 comparative studies reported the same outcome measure. Risk of bias assessment was undertaken for randomised (RoB2, Cochrane) and comparative studies (ROBINS-I, Cochrane).

RESULTS

We included 60 studies, consisting of 7 randomised controlled trials, 13 observational comparative studies and 40 observational case series. All comparative studies reported on shoulder-specific functional outcome scores, 18 on the radiographic occurrence of re-tear and 14 on pain score metrics. All studies contained some risk of bias.Compared with non-augmented repair, a small improvement in shoulder-specific function or pain scores was observed for synthetic patches with a mean improvement of 6.7 points on the University of California Los Angles (UCLA) shoulder score (95% CI 0.1 to 13.4) and 0.46 point reduction on the Visual Analogue Scale (95% CI -0.74 to -0.17), respectively. A reduced likelihood of radiologically observed re-tear was observed for synthetic (risk ratio (RR) 0.41, 95% CI 0.27 to 0.61) and allograft (RR 0.34, 95% CI 0.18 to 0.65) patches. A total of 49 studies reported on the occurrence of complications. Slightly higher crude complication rates were observed following patch-augmented repair (2.1%) than standard repair (1.6%).

CONCLUSIONS

While several studies suggest a decreased failure rate and small improvements in shoulder function and pain following augmented RCR, a paucity of rigorous clinical evaluation, for both effectiveness and safety, prevents firm recommendations.

PROSPERO REGISTRATION NUMBER

CRD42017057908.

Interposition Graft Repair of Irreparable Rotator Cuff Tears: A Review of Biomechanics and Clinical Outcomes

Managing massive irreparable rotator cuff tears is a challenge. Interposition graft repairs to bridge the torn defect are a promising solution. Many graft materials are available for interposition repairs including the following: allografts, autografts, extracellular matrix, and synthetic grafts. Currently, it is unknown how these materials compare biomechanically or in their clinical outcomes when used for interposition graft repairs of massive irreparable rotator cuff tears. Most allografts and autografts are similar, in maximal load and stiffness, to intact rotator cuff tendons. Synthetic grafts have similar maximal load but lower stiffness, whereas extracellular matrix grafts are lower in maximal load and stiffness compared with intact rotator cuff tendons. Overall interposition graft repairs have shown some promising 2-year outcomes in patient and physician-reported functional outcomes, regardless of graft type. Few reported complications or repair failure associated with interposition graft repairs of massive irreparable rotator cuff tears at 2 years postsurgery have been noted.

An in-vitro biomechanical assessment of humeral head migration following irreparable rotator cuff tear and subacromial balloon reconstruction

BACKGROUND

A resorbable subacromial balloon has been developed to address humeral head migration following posterosuperior rotator cuff tears. The purpose of this experimental assessment was to quantify the effect of balloon augmentation on humeral head position.

METHODS

Eight cadaveric shoulders were subjected to 0°, 30°, 60° and 90° of abduction via a shoulder simulator. The deltoid was activated at 40N, then 80N. The subscapularis and infraspinatus with teres minor were then applied independently and together to create four muscle activation states for each deltoid load. The shoulder was tested intact, torn, then with the balloon. The centre of the humeral head was tracked using active optical markers.

RESULTS

When the rotator cuff was torn, the humeral head translated superior by 1.4 ± 1 mm overall (P = 0.009). Following balloon augment, the humeral head translated inferiorly by 2 ± 2 mm relative to the intact state (P = 0.042), and significantly more anterior than the intact (3 ± 2 mm; P = 0.005) state. Rotator cuff variation was only significantly different when the balloon was used, with the subscapularis translating the humeral head posteriorly (P = 0.006).

DISCUSSION

The subacromial balloon inferiorized the humeral head compared to the torn state. Unexpected anterior humeral head translation was attributed to the posterosuperior balloon placement relative to the humeral head.

Use of Platelet-Rich Plasma for the Improvement of Pain and Function in Rotator Cuff Tears: A Systematic Review and Meta-analysis With Bias Assessment

BACKGROUND

Many clinical trials have investigated the use of platelet-rich plasma (PRP) to treat rotator cuff-related abnormalities. Several meta-analyses have been published, but none have focused exclusively on level 1 randomized controlled trials.

PURPOSE

To assess the efficacy of PRP for rotator cuff-related abnormalities and evaluate how specific tendon involvement, the inclusion of leukocytes, and the use of gel/nongel formulations affect pain and functional outcomes.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

The literature was screened following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Baseline, short-term, and long-term data were extracted for the Constant score, University of California, Los Angeles (UCLA) score, visual analog scale (VAS) for pain, retear rate, Simple Shoulder Test (SST), and American Shoulder and Elbow Surgeons (ASES) score. The 100-point modified Coleman Methodology Score (CMS) was used to assess methodological quality. Funnel plots and the Egger test were used to screen for publication bias, and sensitivity analysis was performed to evaluate the effect of potential outliers.

RESULTS

A total of 18 level 1 studies were included in this review, 17 (1116 patients) of which could be included in quantitative analysis. The mean modified CMS was 79.4 ± 10.39. The Constant scores of patients who received PRP were significantly better short term (weighted mean difference [WMD], 2.89 [95% CI, 0.89-4.90]; P < .01) and long term (WMD, 2.66 [95% CI, 1.13-4.19]; P < .01). The VAS scores were significantly improved short term (WMD, -0.45 [95% CI, -0.75 to -0.15]; P < .01). Sugaya grade IV and V retears in PRP-treated patients were significantly reduced long term (odds ratio [OR], 0.34 [95% CI, 0.20-0.57]; P < .01). In PRP-treated patients with multiple tendons torn, there were reduced odds of retears (OR, 0.28 [95% CI, 0.13-0.60]; P < .01). Patients who received leukocyte-rich PRP had significantly better Constant scores compared with the leukocyte-poor PRP group, but there was no difference in VAS scores. Patients receiving PRP gel reported higher Constant scores compared with the controls, whereas those receiving nongel PRP treatments did not, although there was no difference in VAS scores. Long-term odds of retears were decreased, regardless of leukocyte content (leukocyte-poor PRP: OR, 0.36 [95% CI, 0.16-0.82]; leukocyte-rich PRP: OR, 0.32 [95% CI, 0.16-0.65]; all P < .05) or usage of gel (nongel: OR, 0.42 [95% CI, 0.23-0.76]; gel: OR, 0.17 [95% CI, 0.05-0.51]; all P < .01).

CONCLUSION

Long-term retear rates were significantly decreased in patients with rotator cuff-related abnormalities who received PRP. Significant improvements in PRP-treated patients were noted for multiple functional outcomes, but none reached their respective minimal clinically important differences. Overall, our results suggest that PRP may positively affect clinical outcomes, but limited data, study heterogeneity, and poor methodological quality hinder firm conclusions.

Clinical Outcomes Following Biologically Enhanced Patch Augmentation Repair as a Salvage Procedure for Revision Massive Rotator Cuff Tears

PURPOSE

To evaluate the clinical outcomes of patients who underwent biologically enhanced patch augmentation repair for the treatment of revision massive rotator cuff tears.

METHODS

Twenty-two patients who underwent arthroscopic and mini-open rotator cuff repair using a patch augmented with platelet-rich plasma and concentrated bone marrow aspirate (cBMA) for revision massive (≥2 tendons) rotator cuff tears from 2009 to 2014, with a minimum 1-year follow-up, were included in the study. In this procedure the medial side of the graft is secured to the rotator cuff tendon remaining medially. American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test, and postoperative Single Assessment Numerical Evaluation scores were evaluated. To determine the clinical relevance of ASES scores, the minimal clinically important difference, substantial clinical benefit (SCB), and the patient-acceptable symptomatic state (PASS) thresholds were used. Clinical success or failure was defined based on whether the patient reached the SCB threshold. In the laboratory, cellular counting along with the concentration of connective tissue progenitor cells were performed on patch samples from the day of surgery. Scaffolds were processed histologically at days 0, 7,14, and 21 of culture.

RESULTS

Patients had significant improvement in the Simple Shoulder Test (2.6 ± 3.0_pre vs 5.2 ± 4.2_post, P = .01), whereas improvement in pain scores was found to be nonsignificant (5.6 ± 2.5_pre vs 4.2 ± 3.4_post,P = .11) at final follow-up. Mean ASES improved by Δ14.6 ± 33.4 points; however, this did not reach statistical significance (40.2 ± 21.6_pre vs 53.9 ± 31.4_post,P = .10). With regards to ASES score, 45% of patients achieved the minimal clinically important difference, 41% the SCB, and 32% reached or exceeded the PASS criteria. At 21 days, there was a significantly greater cell count in scaffolds from patients who had clinical success than those who were failures (P = .02).

CONCLUSIONS

Only 41% of patients undergoing biologically enhanced patch augmentation repair reached substantial clinical benefit, whereas 32% reached or exceeded the PASS criteria.

LEVEL OF EVIDENCE

Case Series: Level IV.

Superior Capsular Reconstruction With the Long Head of the Biceps Autograft Prevents Infraspinatus Retear in Massive Posterosuperior Retracted Rotator Cuff Tears

BACKGROUND

Materials and patches with increased biomechanical and biological properties and superior capsular reconstruction may change the natural history of massive rotator cuff tears (RCTs).

PURPOSE

To compare structural and clinical outcomes among 3 surgical techniques for the treatment of massive posterosuperior RCTs: double-row (DR) technique, transosseous-equivalent (TOE) technique with absorbable patch reinforcement, and superior capsular reconstruction (SCR) with the long head of the biceps tendon (LHBT) autograft.

STUDY DESIGN

Cohort study; Level of evidence 3.

METHODS

We retrospectively analyzed the 3 techniques in patients who underwent repair of massive posterosuperior RCTs between January 2007 and March 2017. All patients completed preoperative and 24-month postoperative evaluations: range of motion, subjective shoulder value, Simple Shoulder Test, American Shoulder and Elbow Surgeons (ASES) score, visual analog scale for pain, and Constant score. Tendon integrity was assessed with ultrasound 1 year postoperatively.

RESULTS

A total of 82 patients completed the final evaluation (28 patients, DR; 30 patients, TOE + patch; 24 patients, SCR with LHBT). Groups were statistically comparable preoperatively, except for active forward elevation and tendon retraction, which were significantly worse in the SCR group (P = .008 and P = .001, respectively). After 24 months, the mean ± SD scores for the respective groups were as follows: 76 ± 10, 72 ± 15, and 77 ± 10 for the Constant score (P = .35); 84 ± 10, 84 ± 15, and 80 ± 15 for the ASES (P = .61); 9 ± 2, 9 ± 3, and 8 ± 3 for the Simple Shoulder Test (P = .23); 82 ± 15, 80 ± 18, and 75 ± 18 for the subjective shoulder value (P = .29); and 1.4 ± 1.7, 1.8 ± 2, and 1.4 ± 1.4 for the visual analog scale (P = .65). The strength of the operated shoulder was 4 ± 3 kg, 4.7 ± 3 kg, and 6.4 ± 1.6 kg for the DR, TOE + patch, and SCR groups, respectively (P = .006). At 12 months postoperatively, 60.7% (17 of 28) of the DR group, 56.7% (17 of 30) of the TOE + patch group, and 91.7% (22 of 24) of the SCR group remained healed on ultrasound. The infraspinatus tendon remained healed in 75% of the DR group, 76.5% of the TOE + patch group, and 100% of the SCR with the LHBT group (P = .006).

CONCLUSION

In cases of massive posterosuperior RCTs, SCR with the LHBT should be considered a reliable, cost-effective treatment option that protects infraspinatus integrity.

What can the radiological parameters of superior migration of the humeral head tell us about the reparability of massive rotator cuff tears?

Objective

The interrelation and clinical utility of the parameters for superior migration of the humeral head, such as the acromiohumeral interval (AHI), inferior glenohumeral distance (IGHD), and upward migration index (UMI), in the management of massive rotator cuff tears are not clear. The objectives of this study were to identify the relation between AHI, IGHD, and UMI when measured with radiography and MRI and to determine whether superior migration can predict the irreparability of massive rotator cuff tears.

Methods

We retrospectively reviewed the files of 64 consecutive patients who underwent arthroscopic partial or complete repair for massive rotator cuff tears at our institution between August 2015 and August 2018. We recorded both radiography and MRI measurements of AHI, IGHD, and UMI, and further the tangent sign, fatty infiltration of the rotator cuff muscles, and the Patte grade. We performed correlation assessments and multiple logistic regression analysis to identify potential predictors of the reparability of massive rotator cuff tears.

Results

Thirty-five patients had partially reparable and 29 had completely reparable tears. Parameters measured with either radiography or MRI were highly correlated with each other. The radiographic measurements showed a moderate or low correlation with the MRI measurements. All parameters of superior migration of the humeral head on radiography and MRI, the tangent sign, fatty infiltration of the infraspinatus muscle, and the Patte grade showed significant differences between patients with partially and completely repaired tears. Among these, the independent predictors for irreparability was Patte grade = 3.

Conclusion

The AHI, IGHD, and UMI were highly correlated when measured with either radiography or MRI, but not when comparing their radiographic with their MRI values. Furthermore, they were not independent indicators of reparability in massive rotator cuff tears.

The use of a synthetic shoulder patch for large and massive rotator cuff tears - a feasibility study

Background

The aim of this study was to explore the feasibility of using a non-absorbable biocompatible polyester patch to augment open repair of massive rotator cuff tears (Patch group) and compare outcomes with other treatment options (Non-patch group).

Methods

Participants referred to orthopaedic clinics for rotator cuff surgery were recruited. Choice of intervention (Patch or Non-patch) was based on patient preference and intra-operative findings. Oxford Shoulder Score (OSS), Shoulder Pain and Disability Index (SPADI), and Constant score were completed at baseline and 6 months. Shoulder MRI was performed at baseline and 6 months to assess fat fraction and Goutallier classification pre- and post- treatment. Feasibility outcomes (including retention, consent and missing data) were assessed.

Results

Sixty-eight participants (29 in the Patch group, 39 in Non-patch group) were included (mean age 65.3 years). Conversion to consent (92.6%), missing data (0% at baseline), and attrition rate (16%) were deemed successful feasibility endpoints. There was significant improvement in the Patch group compared to Non-patch at 6 months in OSS (difference in medians 9.76 (95% CI 2.25, 17.29) and SPADI: 22.97 (95% CI 3.02, 42.92), with no substantive differences in Constant score. The patch group had a higher proportion of participants improving greater than MCID for OSS (78% vs 62%) and SPADI (63% vs 50%) respectively. Analysis of the 48 paired MRIs demonstrated a slight increase in the fat fraction for supraspinatus (53 to 55%), and infraspinatus (26 to 29%) at 6 months. These differences were similar and in the same direction when the participants were analysed by treatment group. The Goutallier score remained the same or worsened one grade in both groups equally.

Conclusions

This study indicates that a definitive clinical trial investigating the use of a non-absorbable patch to augment repair of massive rotator cuff tears is feasible. In such patients, the patch has the potential to improve shoulder symptoms at 6 months.

Trial registration

ISRCTN, ISRCTN79844053, Registered 15th October 2014 (retrospectively registered).

The Effect of Glenohumeral Fixation Angle on Deltoid Function During Superior Capsule Reconstruction: A Biomechanical Investigation

PURPOSE

To evaluate the effect of dermal allograft fixation at different angles of glenohumeral abduction on deltoid forces during superior capsule reconstruction (SCR).

METHODS

Fifteen cadaveric specimens were tested using a dynamic shoulder simulator. Following testing in the native state, shoulders underwent SCR in 2 of 5 possible fixation angles; 0°, 15°, 30°, 45°, or 60° of glenohumeral abduction, allowing for 6 specimens per group. Angles were measured radiographically with the glenoid fixed perpendicular to the floor. Maximum mean deltoid abduction force was compared among 5 separate conditions within each angle group: (1) native shoulder, (2) complete supraspinatus (SSP) and superior capsule tear, (3) SCR alone, (4) SCR with posterior margin sutured, and (5) SCR with anterior and posterior margins sutured.

RESULTS

SSP tears significantly increased the maximum deltoid forces for all 5 fixation angles compared with the native state (P < .05). Specimens repaired at 0°, 30°, and 45° were unable to restore deltoid forces compared with the native state in any condition (P < .05). SCR at 15° with anterior and posterior margin convergence showed similar abduction forces compared with the native state (P = .19). When fixed at 60° abduction, SCR alone significantly reduced deltoid forces compared to SSP (Δ143N, P < .001) and native (Δ48N, P < .001). No significant differences were found between the 3 repair subtypes (SCR ± anterior/posterior margin repair) in the 60° group.

CONCLUSIONS

SCR with anterior and posterior margin convergence tensioned at 15° of glenohumeral abduction showed similar deltoid abduction force requirements compared with the native state, whereas graft fixation in 60° significantly reduced deltoid force in all SCR conditions.

CLINICAL RELEVANCE

Increased graft tension with a greater abduction angle may provide greater functional outcome by placing less load on the deltoid. In contrast, graft fixation in lower abduction angles may require additional margin convergence to reproduce native forces.

Effectiveness of Dextrose Prolotherapy for Rotator Cuff Tendinopathy: A Systematic Review

OBJECTIVE

To systematically review and evaluate the efficacy and complication profile of prolotherapy using hyperosmolar dextrose solution injection for rotator cuff tendinopathy.

LITERATURE SURVEY

MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials (from inception to 1 July, 2019).

METHODOLOGY

A comprehensive search was completed to identify randomized controlled trials addressing prolotherapy using hyperosmolar dextrose solution for rotator cuff tendinopathy. Two reviewers independently screened the titles, abstracts, and full texts, and then extracted data from eligible studies. All reported outcome measures and complications were analyzed descriptively.

SYNTHESIS

Five studies satisfied inclusion criteria. Included studies analyzed a total of 272 participants with a final follow-up ranging from 6 weeks to 12 months. Prolotherapy differed greatly among studies. Two studies used a multisite enthesis injection protocol while the other three used ultrasound-guided protocols. Two of the studies used an intrasubstance supraspinatus injection and three used a supraspinatus enthesis injection. Control groups consisted of nonoperative rehabilitation including physical therapy and medical management in three studies, supraspinatus saline enthesis injection in one study, and corticosteroid injection in one study. There was statistically significant improvement in pain intensity with multisite injection protocols compared to physical therapy and medical management in both studies. Ultrasound-guided supraspinatus injection trials did not find any statistically significant difference in pain intensity, range of motion, strength, function, or ultrasound characteristics compared to controls of enthesis saline injection or corticosteroid. The complication rate was low, with only 6/272 participants experiencing adverse events consisting of transient increase in pain for 1 to 2 days postintervention.

CONCLUSIONS

Prolotherapy with hyperosmolar dextrose solution is a potentially effective adjuvant intervention to physical therapy for patients with rotator cuff tendinopathy ranging from tendinosis to partial-thickness and small full-thickness tears. Further studies are necessary to determine effects in subpopulations as well as optimal technique including dextrose concentration, volume, and location.

Sub-acromial balloon spacer for irreparable rotator cuff tears: Is it an appropriate salvage procedure?

INTRODUCTION

Irreparable rotator cuff tear (RCT) presents a difficult treatment challenge for the orthopaedic surgeon. Many treatment strategies with varying degrees of success have been performed over the years. One of the suggested surgical treatment options is the use of a biodegradable sub-acromial balloon spacer.

METHODS

A retrospective study of patients treated with sub-acromial balloon spacer between the years 2011 and 2016 was conducted. Mean follow-up time was 14.4 months. Patient charts were reviewed to evaluate the early clinical results and complications of sub-acromial spacer for irreparable RCTs.

RESULTS

The study cohort included 24 shoulders in 22 patients. The average postoperative Disability of the Arm, Shoulder and Hand score was 62.4. The average preoperative University of California at Los-Angeles Shoulder score was 10.9 and improved to 15.9 ( p = 0.001). Forty-six per cent of patients were satisfied with their clinical postoperative outcome. We found moderate-strong positive correlation ( r = 0.64) between preoperative range of motion (ROM) and general satisfaction. None of the postoperative radiographs showed an improvement regarding the proximal migration of the humeral head. In total, four (16.7%) patients experienced postoperative complications, and two (8.3%) patients required an additional surgery as a consequence of a postoperative complication.

CONCLUSION

Our results show unsatisfactory improvement in patients with irreparable RCT treated with the sub-acromial balloon spacer. Careful patient selection with attention to preoperative ROM should be considered.

LEVEL OF EVIDENCE

Therapeutic level IV.

Rationale for Biologic Augmentation of Rotator Cuff Repairs

The structural integrity of rotator cuff repair (RCR) has been a primary focus for shoulder surgeons seeking long-term clinical and functional success. Improvements in surgical techniques have allowed for superior initial biomechanical fixation. However, tendon healing remains a significant clinical problem even after rigid time-zero repair. The lack of long-term healing has led to increased interest in biologic augmentation to improve tendon-to-bone healing. This interest has led to a rise in the investigation of small molecular therapies, cell-based strategies, and tissue-derived treatments offering surgeons a new therapeutic toolbox for potentially improving RCR long-term outcomes. However, the delivery, efficacy, and safety of these treatments remain under investigation. Additional well-designed, high-level studies are of paramount importance in creating evidence-based guidelines for the implementation of new biologic solutions. This review article discusses the current preclinical, translational, and clinical experience with and rationale for biologic augmentation in RCR.

Failure of Dermal Allograft Repair of Massive Rotator Cuff Tears in Magnetic Resonance Imaging and Clinical Assessment

Background

Massive retracted rotator cuff tears represent a therapeutic dilemma, particularly in the young and middle-aged patients who are not appropriate for a reverse total shoulder replacement. Interposition grafting using human dermal allograft offers an alternative treatment.

Methods

A retrospective review of all patients who underwent interposition grafting using human dermal allograft between December 2013 and May 2015 for massive rotator cuff tears at our tertiary referral center was performed. Preoperative and 6 month postoperative magnetic resonance imaging (MRI) assessments were performed in all patients, with postoperative graft integrity being the primary outcome measure. Clinical evaluation was performed using the Oxford shoulder score, Constant score, and Disabilities of the Arm, Shoulder and Hand (DASH) score.

Results

The mean age at the time of follow-up was 54 years. On MRI, 84% of grafts were seen to have failed at 6 months. Strength was grossly reduced on the operative side when supraspinatus and subscapularis were tested; despite this, Constant score (mean, 48.2) was comparable to that in the previous reports. DASH and Oxford scores were a mean of 24.94 and 37.16, respectively.

Conclusions

Based on these results, in particular the MRI findings, we cannot advocate the use of dermal allograft as an interposition graft for the repair of massive rotator cuff tears.

Superior capsular reconstruction for irreparable supraspinatus tendon tears using the long head of biceps: A biomechanical study on cadavers

INTRODUCTION

The superior articular capsule complements the rotator cuff's function in shoulder stability. With irreparable rotator cuff tears, superior capsular reconstruction (SCR) improves dynamic glenohumeral (GH) joint kinematics. We present a novel method of SCR in cadaveric shoulders using the long head of bicep (LHB) tendon instead of previously explored fascia lata autograft, thereby reducing harvest site and suture anchor associated complications.

HYPOTHESIS

This novel method of SCR using the LHB is feasible biomechanically in restoring shoulder stability in irreparable supraspinatus tendon tear.

MATERIALS AND METHODS

Seven cadaveric shoulders were tested in a custom shoulder testing system. Superior translation of the humerus, subacromial contact pressure and area, and glenohumeral range of motion were tested at 0°, 30°, and 60° of glenohumeral abduction in the following conditions: (1) intact shoulder, (2) simulated complete supraspinatus tendon tear, (3) modified SCR using LHB, (4) and modified SCR using LHB and side-to-side repair augmentation.

RESULTS

The complete cuff tear shifted the humeral head superiorly as compared to the intact shoulder. Subacromial peak contact pressure was also increased at 30° and 60° while contact area was increased at 0° and 30°. The modified SCR both with and without side-to-side repair shifted the humeral head inferiorly at 30° and 60°, with contact area further reduced at 60°. Both techniques had comparable results for contact pressure and total rotational range of motion.

CONCLUSION

The LHB with appropriate distal insertion on the greater tuberosity restores shoulder stability in irreparable rotator cuff tears by re-centering the humeral head on the glenoid.

LEVEL OF EVIDENCE

Basic science study, biomechanical testing.

Arthroscopic Superior Capsular Reconstruction for Massive, Irreparable Rotator Cuff Tears: A Systematic Review of Modern Literature

PURPOSE

To systematically review and evaluate the efficacy and complication profile of superior capsular reconstruction (SCR) as a technique to address massive, irreparable rotator cuff tears (MIRCTs).

METHODS

Searches of the Cochrane Database of Systematic Reviews, Embase, MEDLINE, PubMed, and conference abstracts of 4 major conferences identified clinical studies addressing SCR for MIRCTs. Two reviewers independently screened the titles, abstracts, and full texts, extracting data from eligible studies. Reported outcome measures and complications were descriptively analyzed.

RESULTS

A total of 10 studies, 7 full texts and 3 conference abstracts, satisfied the inclusion criteria. The included studies examined a total of 350 shoulders with a mean patient age of 60.6 years and mean follow-up period of 20.6 months postoperatively. Only 4 studies had a minimum of 24-month follow-up data. Statistically significant improvements in pain and function were noted in all studies reporting results, with mean improvement ranging from 29.4 to 68.5 and from 2.5 to 5.9 points across the American Shoulder and Elbow Surgeons score and visual analog scale score, respectively. Mean improvement in range of motion ranged from 21.7° to 64.0° in elevation and from 9.0° to 15.0° in external rotation. Statistically significant improvements in the postoperative acromiohumeral distance were noted in 4 of 5 reporting studies, with a mean increase ranging from 2.2 to 5.0 mm. The combined clinical and radiographic failure and/or retear rate ranged from 3.4% to 36.1%. Complications for all studies included deep infection (0%-2%), symptomatic suture anchor loosening (0%-4%), and severe shoulder contracture (0%-2%).

CONCLUSIONS

Arthroscopic SCR represents an accepted surgical option for patients with MIRCTs, with short-term improvements shown in pain, range of motion, and function. Although early results are promising, further studies are necessary to determine the long-term success of this technique and to better delineate the clinical indications, survivorship, and risk factors for failure in this population.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Porcine Dermal Xenograft as Augmentation in the Treatment of Large Rotator Cuff Tears: Clinical and Magnetic Resonance Results at 2-Year Follow-Up

Purpose  The aim of the present retrospective study is to describe the results obtained at 2-year follow-up by using a porcine dermis-derived collagen membrane implanted as augmentation to treat large rotator cuff tears.

Methods  Thirty-five patients in total were included according to the following criteria: large or massive rotator cuff tear, confirmed during surgery, measuring between 3 and 5 cm in width and stage 1 to 2 fatty infiltration documented at magnetic resonance imaging (MRI). Patients underwent arthroscopic repair of the cuff augmented by the implantation of a porcine dermal collagen membrane. Patients were evaluated up to 24 months after surgery by the Constant score and MRI imaging to assess functional outcomes and re-tear rate. The results obtained were compared to those of a matched cohort of 35 patients operated by arthroscopic repair alone by the same surgical team.

Results  The application of the porcine membrane proved to be safe without scaffold-related adverse events documented. A statistically significant difference in the Constant score in favor of the treatment group was documented at the final evaluation ( p  = 0.036 ). Furthermore, a subgroup analysis revealed that patients treated by augmentation and presenting re-tear at MRI showed a significantly higher functional outcome compared with control patients with MRI evidence of re-tear ( p  = 0.0136).

Conclusion  Arthroscopic repair augmented by porcine dermal xenograft for the treatment of chronic and retracted rotator cuff tears with low-grade fatty degeneration proved to be safe and also effective, with higher functional score compared with the arthroscopic repair alone.

Level of Evidence  This is a Level III, retrospective cohort study.

Arthroscopic-assisted latissimus dorsi transfer for massive rotator cuff tear: a systematic review

INTRODUCTION

This systematic review provides a comprehensive description of different surgical techniques for massive rotator cuff tears (MRCTs) using arthroscopic-assisted latissimus dorsi transfer (A-LDT), reporting clinical outcomes and complications.

SOURCES OF DATA

We searched the literature on Medline (PubMed), Web of Science and Scopus databases using the combined keywords 'latissimus dorsi', 'tendon', 'transfer', 'rotator cuff tears', 'shoulder' and 'arthroscopy' to identify articles published in English, Spanish, French and Italian. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was followed for the manuscript selection.

AREAS OF AGREEMENT

Ten studies (five retrospective and five prospective investigations), all published between 2014 and 2018, fulfilled our inclusion criteria, dealing with 348 (55.7% male) patients, with a mean age of 61.6 years (range 31-83).

AREAS OF CONTROVERSY

A-LDT is a technical demanding procedure. When compared with the open technique, it does not seem to provide significant subjective and objective clinical outcome improvements.

GROWING POINTS

A-LDT seems to yield lesser surgical complications and post-operative stiffness. Sparing the deltoid muscle belly could result in a more effective shoulder post-surgery function.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further comparative randomized controlled trials with longer follow-up are needed to clarify the potentially promising superiority of A-LDT.

Evaluating the Outcomes of Rotator Cuff Repairs With Polytetrafluoroethylene Patches for Massive and Irreparable Rotator Cuff Tears With a Minimum 2-Year Follow-up

BACKGROUND

Massive and irreparable rotator cuff tears are difficult to manage surgically. One technique is to use a synthetic polytetrafluoroethylene (PTFE) patch to bridge the tear. However, there is little information regarding the outcomes of this procedure.

PURPOSE

To determine the ≥2-year outcomes of patients for whom synthetic patches were used as tendon substitutes to bridge irreparable rotator cuff defects.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This retrospective cohort study used prospectively collected data. Patients included those with a synthetic patch inserted as an interposition graft for large and/or irreparable rotator cuff tears with a minimum 2-year follow-up. Standardized assessment of shoulder pain, function, range of motion, and strength was performed preoperatively, at 6 and 12 weeks, and at 6 months and ≥2 years. Radiograph and ultrasound were performed preoperatively, at 6 months, and ≥2 years.

RESULTS

At a mean of 36 months, 58 of 68 eligible patients were followed up, and 53 of 58 (90%) patches remained in situ. Three patches failed at the patch-tendon interface, while 1 patient (2 shoulders/patches) went on to have reverse total shoulder replacements. Patient-ranked shoulder stiffness ( P < .001), frequency of pain with activity and sleep ( P < .0001), level of pain at rest and overhead ( P < .0001), and overall shoulder function improved from bad to very good ( P < .0001) by 6 months. Supraspinatus (mean ± SEM: 29 ± 16 N to 42 ± 13 N) and external rotation (39 ± 13 N to 59 ± 15 N) strength were the most notable increases at the ≥2-year follow-up ( P < .0001). Passive range of motion also improved by 49% to 67%; forward flexion, from 131° to 171°; abduction, from 117° to 161°; external rotation, from 38° to 55°; and internal rotation, from L3 to T10 ( P < .0001) preoperatively to ≥2 years. The most improvement in passive range of motion occurred between 12 months and ≥2 years. The mean (SD) Constant-Murley score was 90 (12), while the American Shoulder and Elbow Surgeons score was 95 (8).

CONCLUSION

At 36 months postoperatively, patients who had synthetic patches used as tendon substitutes to bridge irreparable rotator cuff defects reported less pain and greater overall shoulder function as compared with preoperative assessments. They demonstrated improved range of passive motion and improved strength. The data support the hypothesis that the technique of using a synthetic PTFE patch to bridge a large and/or irreparable tear has good construct integrity and improves patient and clinical outcomes.

Superior Capsular Reconstruction With the Addition of an Acromial Acellular Dermal Allograft Spacer

Superior capsular reconstruction has emerged as a promising technique in the treatment of massive irreparable rotator cuff tears. The technical aspects of the surgery continue to evolve, and scientific studies to evaluate these techniques are emerging. One such area of interest concerns the appropriate thickness of the graft and its role as a spacer. The original description of the graft was an autograft tensor fascia lata, which was folded to achieve a thickness of around 8 mm. It has been demonstrated that an 8-mm graft is superior biomechanically to a 4-mm graft, which exceeds the typical human dermal allograft thickness. Herein we describe a technique in which an acellular human dermal allograft was used to perform a superior capsular reconstruction and the remainder of the graft was used to resurface the undersurface of the acromion. This modification of the technique allows for arthroscopic acromial resurfacing, as well as effectively doubling the thickness of the spacer function of the graft. The technique and justification are described in detail, and this has become the senior author's standard approach to the massive irreparable rotator cuff tear in patients with Hamada stages 2 and 3.

The use of a subacromial spacer-inspace balloon in managing patients with irreparable rotator cuff tears

Aim

The objective of this prospective non-randomized study was to establish the role of biodegradable sub-acromial spacer (InSpace™) insertion in the management of patients with massive irreparable rotator cuff tear by reporting beneficial effects on the pain relief and functional outcomes in these patients.

Methods

This is a prospective non-randomized study of patients treated for irreparable cuff tears during a period between January 2014 and November 2016.14 patients with symptomatic massive irreparable rotator cuff tears were managed with arthroscopic debridement and implantation of a biodegradable subacromial spacer and were followed up for at least one year (8-16 m). Inclusion criteria were patients with irreparable rotator cuff tears that failed the conservative management, with muscle retraction (Patte > stage 2), muscle atrophy, and fatty infiltration (Goutalier type 3). Patients with osteoarthritis grade 3 in the Hamada classification and/or without preserved passive motion were excluded from our study. Outcome measures included pre and postoperative, the range of motion, Constant and Oxford shoulder scores. The decision to perform surgery was made after failure of nonoperative treatment and rehabilitation (massive rotator cuff tear protocol, reading shoulder unit)for at least six months.

Results

Fourteen shoulders (14 patients, ten male four female) met the inclusion criteria. The mean age of patients was 76.2 (70-85) years. During the last follow-up (8-16 months mean 12.6 months), the range of motion was significantly increased in all patients with anterior elevation (from 80 to 105°), abduction (from 70 to 110°), and external rotation (from 25 to 35°). The mean Constant score was also significantly (P < 0.001) improved from 22.5 (13-33) preoperatively to 51.4 (30-64) at the last follow-up. The Oxford shoulder score improved from 26 preoperatively (21-28) to 48.2 postoperatively (34-56). No night pain following surgery and ADL increased by 40%, which is significant in these patients. No significant perioperative complications were found except for one patient who had a spacer migration. However, no action was required in that case.

Conclusions

Arthroscopic implantation of a subacromial spacer for irreparable rotator cuff tear resulted in a noticeable improvement in pain relief and shoulder function at a mean 12.6 months follow up. It is a quick, safe and a minimally invasive procedure that is suitable for elderly patients with irreparable cuff tears and medical co-morbidities.